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Young man with non-resolving wart

Discussion in 'General Issues and Discussion Forum' started by kri55y, Feb 20, 2014.

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  1. kri55y

    kri55y Welcome New Poster


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    i have been treating a healthy young man aged in his early 30s with a plantar wart that is not responding to treatment.

    Duration of wart approx 2-3 years, treatments on and off with GPs and podiatrists.
    Previous GPs have been treating with liquid nitrogen and i have been treating him for the last 4 months with both liquid nitrogen and salicylic acid.

    can anyone suggest any other treatments to try other than surgery?
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Cut it out.
     
  3. Rob Kidd

    Rob Kidd Well-Known Member

    Is it painful? If not, and he is not immunosuppressed, why are you treating it at all? If it is painful, back to basic; are you sure of your first diagnosis? Time to get outside your square. Rob
     
  4. davidh

    davidh Podiatry Arena Veteran

    As previous advice.
    If you're not sure about it refer on.

    The days of being able to muck around with VPs which don't respond are long-gone. Be sure of your diagnosis and treat accordingly, or refer on for definitive diagnosis and treatment.
     
  5. blinda

    blinda MVP

    Agree with Rob and David.

    Definitive dx is paramount with ANY lesion not responding to tx. That said, HPV-1 subtypes are notoriously difficult to resolve and can hang around for up 10+ years in healthy adults. If appropriate, I often needle then curette the lesion. If it`s asymptomatic, ie non-painful nor interfering with QOL, then monitoring the lesion is sometimes the best option.
     
  6. Admin2

    Admin2 Administrator Staff Member

    Related Threads:
    Other threads tagged with Verruca
     
  7. gdockdockery

    gdockdockery Member

    I would recommend several things when dealing with a long-standing and non-responsive wart in a 30+ year-old male: first, confirm that the patient is not immunocompromised, and then, take a couple of small biopsies and have them examined by a dermatopathologist (rather than a general pathologist). Once you have the answer to these two questions, you may proceed. I become more aggressive when I am sure of the diagnosis and I would curette the entire area and continue topical care to start. I typically have several treatments going at once for these resistant lesions. Dock
     
  8. blinda

    blinda MVP

    Hi Gary,

    Thanks for taking the time to respond to this thread. I have a great deal of respect for your thoughts and expertise. Just for clarity, could you please expand on the two questions, namely;

    1) How would your treatment plan differ from an immune-competent to an immune-compromised patient? And,
    2) What are you specifically seeking from biopsy? Is it definitive diagnosis of HPV (as opposed to a malignancy), or the HPV sub-type? If the latter, do you subscribe to sub-type specific treatment?

    Kind regards,
    Bel
     
  9. gdockdockery

    gdockdockery Member

    Bel
    I know form years of experience that the immunocompromised patient is much more difficult to treat as far as warts is concerned and I will have to put on my patience hat and be willing to stick with it longer. In many of my own cases that might be years of treatment. As far as getting biopsy confirmation of a resistant wart, it is simply to convince myself that I am not dealing with a number of other papulosquamous dermatological conditions, such as large seborrheic keratosis, isolated psoriasis, squamous cell carcinoma, keratoacanthoma, etc. I know that wart typing and sub-typing is beginning to be written about, but I have not gotten to that stage of sophistication. I still have certain treatments that work on particular body areas better than others and when resistant, I throw everything at them. A good general treatment review article: Lipke MM: An Armamentarium of wart treatments. Clin Med Res. 4(4):273-293, 2006. Dock
     
  10. blinda

    blinda MVP

    Thanks for the reply. I agree that definitive diagnosis is incredibly important in recalcitrant lesions.

    Forgive me for asking further questions; your comment, which I have highlighted in bold, grabbed my attention. I find it fascinating that sub-type classification is determined, not only by DNA differences, but also by site of the lesion and that this is an influential factor in treatment outcomes. Which sites have you found to be more resistant than others and why, in your expert opinion, do you think this may be?

    I also agree with the observations that Lipke made. In particular with the statement "although evidenced based reviews with guidelines have been published, they do not cover treatments that have yet to be subjected to blinded randomized, controlled clinical trials." Moreover, Lipke asserted that "lack of robust evidence of a therapy, which has not been subjected to such rigorous scientific testing, does not mean that it is not worth knowing about nor worthy of use in practice, particularly when a specific treatment has been utilised and reported, with a reasonably high clinical success rate." I cited this in my review of clinical practice which was published last year.

    http://www.mdpi.com/2077-0383/2/2/13

    Cheers,
    Bel
     
  11. reckles

    reckles Member

    Excise lesion whole, if possible, with wide margins intact, and send for pathology. Don't muck about with things that won't work. You won't know what this is until you have the lesion analyzed.
     
  12. anthony watson

    anthony watson Active Member

    Hi
    Have been reading the post and the very in depth answers.

    some amazing advice from our colleagues in the USA.

    I however imagine that if the patient has no medical history that could raise concerns it may be tricky to get the GP to refer to dermatology or take a biopsy.

    Laser therapy "the low level type" may be worth ago but don't use any therapy if you are not sure it is a VP as may do more harm.

    check out the clinical reviews by Omega laser systems may be useful.

    Good luck
    Anthony
     
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